By Counterforce Health Team in Cometriq (cabozantinib) —

How to Get Cometriq (Cabozantinib) Covered by Cigna in Illinois: Complete Timeline Guide

Answer Box: Getting Cometriq (cabozantinib) covered by Cigna in Illinois typically takes 5-72 hours for prior authorization decisions under Illinois law. The fastest path: 1) Have your oncologist submit complete PA documentation (pathology, imaging, tumor markers) via Cigna's electronic portal, 2) Request expedited review if urgent (24-hour decision), 3) If denied, file internal appeal within 180 days, then external review within 30 days if needed. Start by calling Cigna member services to confirm formulary status and PA requirements.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization PA required before dispensing Cigna formulary, member portal Cigna PA Policy
Diagnosis Progressive, metastatic medullary thyroid carcinoma Pathology report, oncology notes FDA Label
Formulation Cometriq capsules only (not Cabometyx tablets) Prescription, NDC verification Cigna Policy
Prescriber Oncologist or endocrinologist Provider credentials NCCN Guidelines
Specialty Pharmacy Accredo or designated network Member ID card, Cigna portal Express Scripts

Step-by-Step: Fastest Path to Approval

1. Verify Coverage and Requirements (Day 0)

Who: Patient or clinic staff
Action: Call Cigna member services (number on ID card) to confirm:

  • Cometriq is on your specific formulary
  • PA requirements for your plan type
  • Designated specialty pharmacy requirements

2. Gather Required Documentation (Days 0-1)

Who: Oncologist's office
Documents needed:

  • Pathology report confirming "medullary thyroid carcinoma"
  • Recent imaging (CT/MRI/PET) showing metastatic/progressive disease
  • Tumor marker trends (calcitonin, CEA levels over time)
  • Oncology treatment notes documenting progression and treatment rationale

3. Submit Complete PA Request (Day 1-2)

Who: Prescribing physician
How: Electronic submission via Cigna provider portal or CoverMyMeds
Timeline: Illinois law requires decisions within 5 calendar days for non-urgent, 48 hours for urgent cases

4. Request Expedited Review if Urgent (Day 1-2)

Who: Prescribing physician
Criteria: Disease progression that may "seriously jeopardize life, health, or ability to regain maximum function"
Timeline: 24-48 hour decision under Illinois Prior Authorization Reform Act

5. Monitor Decision Timeline (Days 1-5)

Who: Patient and clinic
Action: Track PA status through Cigna member portal or provider portal
Escalation: If no decision within statutory timeframes, contact Illinois Department of Insurance

6. If Approved: Coordinate Specialty Pharmacy (Day 5-7)

Who: Patient with clinic support
Action: Contact Accredo or designated specialty pharmacy to schedule delivery
Timeline: First shipment typically within 3-5 business days of approval

7. If Denied: File Appeal Immediately (Day 5-10)

Who: Patient, prescriber, or authorized representative
Timeline: 180 days for internal appeal, then 30 days for external review in Illinois
Required: Written appeal with additional clinical documentation

Illinois Timeline Requirements

Illinois' Prior Authorization Reform Act sets specific deadlines that Cigna must follow for fully-insured plans:

Standard Prior Authorization

  • Non-urgent requests: 5 calendar days maximum after receiving complete information
  • Urgent requests: 48 hours maximum
  • Prescription drugs: Often faster internal standards (24-72 hours)

Appeal Timelines

Note: Self-funded employer plans may follow different federal timelines. Check your plan documents or ID card to determine if Illinois state law applies.

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Wrong formulation (Cabometyx vs Cometriq) Resubmit with correct NDC for Cometriq capsules New prescription specifying capsules
Insufficient diagnosis documentation Provide complete pathology report Pathology stating "medullary thyroid carcinoma"
Lack of progression evidence Submit recent imaging and tumor markers Comparative CT/MRI showing progression
Not medically necessary File appeal with clinical rationale Oncology notes, guidelines citations
Missing prescriber qualifications Verify oncologist credentials Board certification documentation

Appeals Process for Illinois Members

Internal Appeals (First Level)

Timeline: File within 180 days of denial
How to file:

  • Online: Cigna member portal
  • Phone: Number on denial letter
  • Mail: Address provided in denial notice

Required information:

  • Member ID and claim number
  • Reason for appeal
  • Additional medical records
  • Prescriber support letter

External Review (Independent)

When: After internal appeal denial
Timeline: 30 days from final adverse determination
Process: Illinois Department of Insurance coordinates independent physician review
Cost: Free to members (insurer pays review costs)

How to request:

Expedited Appeals

Criteria: Delay would seriously jeopardize health
Timeline: 24-72 hours for decision
Documentation: Physician attestation of urgency required

Cost-Saving Options

Manufacturer Support

Exelixis Access Services (EASE):

  • Prior authorization assistance
  • Commercial insurance copay support
  • Free drug program for uninsured/underinsured
  • Contact: Cometriq manufacturer website

Medicare Part D (2025)

  • Annual out-of-pocket cap: $2,000
  • Prescription Payment Plan available to spread costs monthly
  • Extra Help program for low-income beneficiaries

State Resources

When navigating complex insurance appeals, specialized services like Counterforce Health can help patients and clinicians turn denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to craft point-by-point rebuttals aligned with payer requirements.

FAQ

How long does Cigna take to approve Cometriq in Illinois?
Under Illinois law, Cigna must decide within 5 calendar days for standard requests and 48 hours for urgent cases. Many specialty drug PAs are processed faster, often within 24-72 hours.

What if Cometriq is not on my Cigna formulary?
Request a formulary exception through your prescriber. Include medical necessity documentation and cite FDA approval for medullary thyroid cancer. Appeals follow the same timeline as PA denials.

Can I use retail pharmacy for Cometriq?
Most Cigna plans require specialty pharmacy (typically Accredo) for Cometriq. Using retail pharmacy often results in claim rejection even with PA approval.

Does step therapy apply to Cometriq?
For FDA-approved metastatic medullary thyroid cancer indication, step therapy requirements are uncommon since limited alternatives exist. Off-label use may trigger step therapy requirements.

What's the difference between Cometriq and Cabometyx for insurance?
These are not interchangeable. Cometriq (capsules) is FDA-approved for medullary thyroid cancer; Cabometyx (tablets) is approved for kidney and liver cancer. Using the wrong formulation triggers automatic denial.

How do I request expedited review?
Your prescriber must document that delay would seriously jeopardize your health. Submit this with the initial PA or appeal request, clearly marking it as "expedited" or "urgent."

From our advocates: We've seen cases where patients received denials simply because the prescription specified "cabozantinib tablets" instead of "Cometriq capsules" for medullary thyroid cancer. Always verify the exact formulation and NDC codes before submission to avoid unnecessary delays.

When to Escalate

Contact these Illinois resources if Cigna doesn't meet statutory deadlines or denies medically necessary treatment:

Illinois Department of Insurance (IDOI)

Illinois Attorney General Health Care Bureau

  • Health Care Helpline: 1-877-305-5145
  • Can intervene informally with insurers
  • Assists with complex appeal cases

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage varies by plan. Consult your healthcare provider for medical decisions and your insurance company for coverage details. For personalized assistance with Illinois insurance appeals, contact the Illinois Department of Insurance consumer assistance program.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.